Project Summary/Abstract The goal of this project is to reduce the high mechanical and infectious complication rates of Central Venous Catheter (CVC) placement through the development and implementation of enhanced training methods; specifically, through the innovative concepts of Dynamic Haptic Robotic Training (DHRT) and the advanced DHRT (DHRT+). Building on the progress of the PIs original R01 the proposed goal will be accomplished through the completion of the three specific aims. Specific Aim 1 Develop and implement whole procedure training through the integration of a mixed reality smart tray, advanced testing surface, and high functional fidelity virtual ultrasound imaging. In this aim, the novel concept of whole procedure training will be pursued, where all 4 key steps of the CVC procedure are automatically trained. In addition optimized high fidelity real time virtual ultrasound images will be developed through advanced modeling. The fidelity of these advancements will be assessed through quantitative measurements and expert panel evaluation. Specific Aim 2 Develop, implement, and evaluate the impact of adaptive feedback and assessment on resident learning and surgical performance. In this aim, the development of optimal performance metrics and assessment strategies will be investigated through expert and resident testing. In addition the impact of the structure, type, components, and timing of adaptive feedback will be explored. Specific Aim 3 Assess the wide-spread integration impact of the DHRT+ system on patient outcomes and surgical performance through its incorporation into the residency curricula at Hershey Medical Center (Hershey, PA) and Cedars-Sinai Medical Center (Los Angeles, CA). In the final aim, long-term skill transfer and the impact of patient safety from DHRT and DHRT+ training will be assessed. Specifically, 625 residents will be monitored as they progress through their first year at their respective institutions, Hershey Medical Center and Cedars-Sinai Medical Center. The mechanical and procedural complications they encounter on their first 5 supervised CVC procedures in the clinic will be assessed. In addition, mechanical and infectious complication rates will be recorded for the residents' first CVC patient.